Decoding the persistence of delayed hospital discharge: An in-depth scoping review and insights from two decades.

OBJECTIVE: This article addresses the persistent challenge of Delayed Hospital Discharge (DHD) and aims to provide a comprehensive overview, synthesis, and actionable, sustainable plan based on the synthesis of the systematic review articles spanning the past 24 years. Our research aims to comprehensively examine DHD, identifying its primary causes and emphasizing the significance of effective communication and management in healthcare settings. METHODS: We conducted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) method for synthesizing findings from 23 review papers published over the last two decades, encompassing over 700 studies. In addition, we employed a practical and comprehensive framework to tackle DHD. Rooted in Linderman's model, our approach focused on continuous process improvement (CPI), which highlights senior management commitment, technical/administrative support, and social/transitional care. Our proposed CPI method comprised several stages: planning, implementation, data analysis, and adaptation, all contributing to continuous improvement in healthcare delivery. This method provided valuable insights and recommendations for addressing DHD challenges. FINDINGS: Our DHD analysis revealed crucial insights across multiple dimensions. Firstly, examining causes and interventions uncovered issues such as limited discharge destinations, signaling unsustainable solutions, and inefficient care coordination. The second aspect explored the patient and caregiver experience, emphasizing challenges linked to staff uncertainty and negative physical environments, with notable attention to the underexplored area of caregiver experience. The third theme explored organizational and individual factors, including cognitive impairment and socioeconomic influences. The findings emphasized the importance of incorporating patients' data, recognizing its complexity and current avoidance. Finally, the role of transitional and social care and financial strategies was scrutinized, emphasizing the need for multicomponent, context-specific interventions to address DHD effectively. CONCLUSION: This study addresses gaps in the literature, challenges prevailing solutions, and offers practical pathways for reducing DHD, contributing significantly to healthcare quality and patient outcomes. The synthesis introduces the vital CPI stage, enhancing Linderman's work and providing a pragmatic framework to eradicate delayed discharge. Future efforts will address practitioner consultations to enhance perspectives and further enrich the study. PATIENT OR PUBLIC CONTRIBUTION: Our scoping review synthesizes and analyzes existing systematic review articles and emphasizes offering practical, actionable solutions. While our approach does not directly engage patients, it strategically focuses on extracting insights from the literature to create a CPI framework. This unique aspect is intentionally designed to yield tangible benefits for patients, service users, caregivers, and the public. Our actionable recommendations aim to improve hospital discharge processes for better healthcare outcomes and experiences. This detailed analysis goes beyond theoretical considerations and provides a practical guide to improve healthcare practices and policies.

The role of support and sustainability elements in the adoption of an online self-management support system for chronic illnesses.

The direct cost of treating chronic disease in Canada has risen to an average of 58% of healthcare spending. Thus, more attention is being directed to technologically supported health self-management and lifestyle change, to help patients mitigate and manage their own conditions. This study investigates how support elements (decision support and education) and sustainability elements (rewards systems), can help to motivate patients to adopt proposed technologies. A proposed model was tested using data collected from two potential user groups: 198 online and 83 in-person, using an identical survey. Although the system was built and ready to use at the time this study was conducted, in order to keep the experience of both groups identical, a video simulation (of the system) was used to familiarize both groups of users with the system. The study reveals that: individual perceptions on usability, ease of use, and hedonic motivation were influenced by the proposed support elements. Support elements enhance user perceptions of usability and ease of use, while sustainability elements positively affect user motivations, thus encouraging their decisions to adopt and use the technology. The study implies that, for better success at helping patients to self-manage their health, special attention should be paid to support and sustainability elements.

Perceptions of sulphadoxine-pyrimethamine use among pregnant women in sub-Saharan Africa: a scoping review.

Background: Malaria is a major global public health issue that disproportionately affects pregnant women in sub-Saharan Africa. The World Health Organization recommends intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) for its control. Despite its proven efficacy, drug uptake remains low. Sulphadoxine-pyrimethamine (SP) safety concerns have been cited as one of several reasons for this low uptake. Methods: We conducted a scoping review using the Arksey and O'Malley framework and the health belief model to investigate perceptions of SP use among pregnant women in sub-Saharan Africa. We looked for peer-reviewed publications in five international databases. Results: The review included 19 articles out of a total of 246. It showed that pregnant women in sub-Saharan Africa have a good understanding of malaria and its consequences, but this does not necessarily translate into increased IPTp-SP uptake. It is worrisome to know that some pregnant women (from 2 studies) did not believe that SP use is beneficial, and several participants (from 4 studies) were unsure or did not see the drug as an effective intervention. Many pregnant women believe SP harms them, their partners, or their unborn children. Conclusions: Healthcare professionals should continue prescribing and encouraging pregnant women to use SP for malaria prevention until a better substitute becomes available.

The effect of the Ontario stay-at-home order on Covid-19 third wave infections including vaccination considerations: An interrupted time series analysis.

The Covid-19 global pandemic that began in March 2020 was not fully mitigated through governmental Non-Pharmaceutical Interventions (NPIs) and continued to infect people and take lives through 2021. Since many countries were affected by the second, third, and fourth waves of Covid-19, governments extended and strengthened NPIs, but these actions led to citizen protests and fatigue. In this study, we investigate the effect of a lockdown policy on Covid-19 third wave implemented by the province of Ontario, Canada, on April 3rd 2021, followed by a stay-at-home order on April 7th 2021 while free Covid-19 testing and vaccination were in progress. Herein, the effect of both NPIs and vaccination are considered simultaneously. We used the prevalence of Covid-19 cases, tests, and administered vaccines data reported publicly by the Government of Ontario on their website. Because mobility changes can reflect the behaviors and adherence of residents with a stay-at-home order, Covid-19 community mobility data for Ontario provided by Google was also considered. A statistical method called interrupted time series was used to analyze the data. The results indicated that, although vaccinations helped to control the Covid-19 infection rate during this time, the stay-at-home order caused a rate reduction by decreasing the trend of the Covid-19 prevalence by 13 (±0.8962) persons per million daily and the level by 33 (±7.6854) persons per million. Furthermore, the stay-at-home order resulted in approximately a 37% reduction in Covid-19 prevalence one week after the intervention's effective date. Therefore, Ontario's strict lockdown policy, including several NPIs, mitigated the Covid-19 surge during the third wave. The results show that even when vaccination is in progress, strict NPIs such as lockdown is required to control Covid-19 waves, and early re-openings should be avoided. These results may also be useful for other countries that have implemented delayed vaccination schedules.

A comparison of physician pre-adoption and adoption views on electronic health records in Canadian medical practices.

BACKGROUND: There is a major campaign involving large expenditures of public money to increase the adoption rate of electronic health record (EHR) systems in Canada. To maximize the chances of success in this effort, physician views on EHRs must be addressed, since user perceptions are key to successful implementation of technology innovations. OBJECTIVE: We propose a theoretical model comprising behavioral factors either favoring or against EHR adoption and use in Canadian medical practices, from the physicians' point of view. EHR perceptions of physicians already using EHR systems are compared with those not using one, through the lens of this model. METHODS: We conducted an online cross-sectional survey in both English and French among medical practitioners across Canada. Data were collected both from physicians using EHRs and those not using EHRs, and analyzed with structural equation modeling (SEM) techniques. RESULTS: We collected 119 responses from EHR users and 100 from nonusers, resulting in 2 valid samples of 102 and 83 participants, respectively. The theoretical adoption model explained 55.8% of the variance in behavioral intention to continue using EHRs for physicians already using them, and 66.8% of the variance in nonuser intention to adopt such systems. Perception of ease of use was found to be the strongest motivator for EHR users (total effect .525), while perceptions of usefulness and of ease of use were the key determinants for nonusers (total effect .538 and .519, respectively) to adopt the system. Users see perceived overall risk associated with EHR adoption as a major obstacle (total effect -.371), while nonusers perceive risk only as a weak indirect demotivator. Of the 13 paths of the SEM model, 5 showed significant differences between the 2 samples (at the .05 level): general doubts about using the system (P = .02), the necessity for the system to be relevant for their job (P < .001), and the necessity for the system to be useful (P = .049) are more important for EHR nonusers than for users, while perceptions of overall obstacles to adoption (P = .03) and system ease of use (P = .042) count more for EHR users than for nonusers. CONCLUSIONS: Relatively few differences in perceptions about EHR system adoption and use exist between physicians already using such systems and those not yet using the systems. To maximize the chances of success for new EHR implementations from a behavioral point of view, general doubts about the rationale for such systems must be mitigated through improving design, stressing how EHRs are relevant to physician jobs, and providing substantiating evidence that EHRs are easier to use and more effective than nonusers might expect.

An international experience of electronic communication and implementation of eHealth solutions in a vascular surgery clinic.

INTRODUCTION: Communication is key to any successful relationship with the patient-physician partnership being no different. Recent advances in technology have provided us with an array of new communication tools such as the mobile phone, computer, internet, and email. This new technology has revolutionized communications; however, limitations to their widespread use include access, literacy, and willingness for both the physician and patient to change. METHODS: To gather international data, questionnaires were completed by patients attending vascular surgery outpatient clinics in hospitals in Ireland and Canada. RESULTS: Five hundred ninety-seven patients participated in the study. Of the participants, 83.2% were over 50 years old. The mean age was 63.1 years, with a range of 18-95 years. Overall, home phone call was the most preferred method of communication with 41.0% of patients selecting this option. Of the patients, 82.4% had a mobile phone but just 48.5% use text message. In those over the age of 70, 72.1% use a mobile phone and just 25.3% use text message. Of the participants, 64.1% had access to a computer, and 67.2% had access to the internet with a decline in the usage of both with increasing age. DISCUSSION: Within this patient population, the use of technologies decreases with increasing age of the patients. This demonstrates a large population of service users who are contented with conventional methods of communication. Change within healthcare ICT is inevitable, and therefore, these patients need to be guided and educated to allow a smooth transition from the old to the new.

Factors of adoption of mobile information technology by homecare nurses: a technology acceptance model 2 approach.

Pervasive healthcare support through mobile information technology solutions is playing an increasing role in the attempt to improve healthcare and reduce costs. Despite the apparent attractiveness, many mobile applications have failed or have not been implemented as predicted. Among factors possibly leading to such outcomes, technology adoption is a key problem. This must be investigated early in the development process because healthcare is a particularly sensitive area with vital social implications. Moreover, it is important to investigate technology acceptance using the support of scientific tools validated for relevant information systems research. This article presents an empirical study based on the Technology Acceptance Model 2 in mobile homecare nursing. The study elicited the perceptions of 91 Canadian nurses who used personal digital assistants for 1 month in their daily activities. A partial least squares modeling data analysis revealed that nurse's perception of usefulness is the main factor in the adoption of mobile technology, having subjective norm and image within the organization as significant antecedents. Overall, this study was the first attempt at investigating scientifically, through a pertinent information systems research model, user adoption of mobile systems by homecare nursing personnel.

FHIRForm: An Open-Source Framework for the Management of Electronic Forms in Healthcare.

Electronic Forms (E-Forms) for data capture are vital for most health information systems in public health and clinical research. Standardized electronic forms ensure accurate data collection, consistent form rendering, easy maintainability, and interoperability. Adopting an innovation research method we explore the challenges of standardized data capture in healthcare and offer a pragmatic solution. We appraise existing standards and software to propose the list of requirements for an ideal E-form framework. Our proposed solution leverages FHIR specification and existing open-source software tools. We discuss how our open-source solution can be extended collaboratively and discuss its value using InterRAI instruments as examples.

Would people pay for text messaging health reminders?

The aim of this study is to determine the time and financial limitations that people would accept for using a telehealth service consisting of wireless text messaging reminders to improve adherence to a recommended healthy regimen. An empirical study based on a 1-month trial of a prototype system that studied adherence to a specified healthy behaviour was conducted. Fifty-one participants received daily cell phone text messaging reminders on taking one vitamin C pill daily for preventive reasons. At the end of the trial they answered a survey regarding their willingness to pay for and to stay with such a service, if offered. If usage were free, only 45% of the participants would continue to use it for a long indefinite period of time. If the usage were for a fee, 29% of the participants would use the service just a few weeks; 28% would use it an indefinite period of time if they could see its usefulness and if the cost were reasonable. The median amount indicated by the participants as a reasonable monthly fee for such a service was $5. Although the study did not evaluate perceived usefulness to use the telehealth service explicitly, a benefit perception proved to condition participant willingness to use the service and to pay for it, if necessary. If people perceive usefulness, they want to use the service, even for a fee. A free service would not be used if it is not perceived as beneficial.

Barriers to technology use among older heart failure individuals in managing their symptoms after hospital discharge.

BACKGROUND: In North America, heart failure (HF) is the leading cause for hospital readmission. Supportive technology, such as computers and tablets, could potentially assist patients with self-care to manage their condition after hospital discharge; however, older individuals have difficulties in adopting technology to manage their condition. METHOD: This study used a mixed methods design to identify barriers to technology use in HF self-care. In the qualitative phase, semi-structured interviews were conducted with 18 HF patients and 10 informal caregivers or care partners (CP). In the quantitative phase, five questionnaires were administered to 15 patients and 8 CP: Montreal Cognitive Assessment; Short Literacy Survey and Subjective Numeracy Scale; Self-Care of HF Index; Knowledge Assessment Questionnaire; and Patient Activation Measure. RESULTS: In the qualitative phase, five themes emerged regarding engagement in self care and technology use: knowledge level of HF; level of willingness to ask questions related to HF; confidence level in making health-related decisions individually; level of technology usage in daily activities; and self-recording of health measurements. Quantitative analysis found that most HF patients had mild cognitive impairment (MCI), adequate health numeracy levels to understand and manage their health condition, high confidence levels in managing their condition and willingness to engage in self-care. There was variation in willingness to adopt technology. CONCLUSION: Patients were willing to engage in HF self-care however they relied on CPs who were more willing to ask questions about HF. Technology tools may assist in HF self-care, but they must be tailored for use among older individuals.

A framework for mobile healthcare answers to chronically ill outpatient non-adherence.

Non-adherence (also known as 'non-compliance') is a major barrier undermining healing efforts within out-of-hospital self-management programmes, resulting in waste of human and social resources. This study suggests a theoretical framework of activities through which mobile patient solutions might address non-adherence determinants in a broader context of clinical interventions. The goal of the paper is to explore a dilemma associated with such interventions: the uncertainty regarding the level of patient involvement and technology support. We follow a critical orientation approach in discussing this multi-faceted conundrum: we summarise the latest vision on adherence factors, we suggest several types of interventions through which mobile healthcare solutions could address them, and we explore in detail the dilemma of patient and technology roles. We conclude that there is no universally optimal solution, and practical conditions depending on patient, disease, treatment and healthcare system are determining factors in prescribing the level of patient involvement and technology support. Our work is intended to stimulate further research into the nature of mobile solutions in health care and, especially, into patient acceptance aspects, in an endeavour to contribute to improving adherence with minimum obtrusiveness.

Perceptions of chronically ill and healthy consumers about electronic personal health records: a comparative empirical investigation.

OBJECTIVE: To develop a model of consumer perceptions of electronic personal health records (PHRs) and validate it in a comparative study between consumers who report having a chronic illness and those who report being well. MATERIALS AND METHODS: A model of PHR use motivators and barriers was built and tested through a national survey across Canada. Data were collected from 800 individuals, 18 years or older. Half reported having a chronic illness or disability and half reported being well. Analyses were performed with structural equation modelling techniques. RESULTS: A total of 389 answers from chronically ill and 383 from well participants were collected. Perceived usefulness was the key explanation of the intention to use PHRs for both ill and well people (total effect of 0.601 and 0.565, respectively) followed by security, privacy and trust in PHRs (total effect of 0.377 and 0.479, respectively). Conversely, computer anxiety was perceived as a significant barrier (total effect of -0.327 for ill individuals and -0.212 for well individuals). DISCUSSION: The model proposed was appropriate in explaining key consumer positive and negative perceptions on electronic PHR use. We found little difference in perceptions of electronic PHRs between chronically ill and well individuals, although self-reporting their health status might have influenced the results. CONCLUSIONS: To increase the adoption rate of electronic PHRs among both chronically ill and well consumers it is necessary to reinforce consumer perceptions of the usefulness of and trust in these eHealth technologies while mitigating their anxieties about computer use in general.

Online self-management interventions for chronically ill patients: cognitive impairment and technology issues.

INTRODUCTION: As the fraction of the population with chronic diseases continues to grow, methods and/or technologies must be found to help the chronically ill to take more responsibility to self-manage their illnesses. Internet based and/or mobile support for disease self-management interventions have often proved effective, but patients with chronic illnesses may have co-occurring cognitive impairment, making it more difficult for them to cope with technologies. Many older patients are also not familiar with technologies or they may have cognitive disabilities or dementia that reduce their ability to self-manage their healthcare. On-line solutions to the needs of chronically ill patients must be investigated and acted upon with care in an integrated manner, since resources invested in these solutions will be lost if patients do not adopt and continue to use them successfully. OBJECTIVES: To review the capabilities of online and mobile support for self-management of chronic illnesses, and the impacts that age and disease-related issues have on these interventions, including cognitive impairment and lack of access or familiarity with Internet or mobile technologies. METHODS: This study includes a review of the co-occurrence of cognitive impairment with chronic diseases, and discusses how cognitive impairment, dyadic caregiver patient support, patient efficacy with technology, and smart home technologies can impact the effectiveness and sustainability of online support for disease self-management. RESULTS: Disease self-management interventions (SMIs) using online patient centered support can often enable patients to manage their own chronic illnesses. However, our findings show that cognitive impairment often co-occurs in patients with chronic disease. This, along with age-related increases in multiple chronic illnesses and lack of technology efficacy, can be obstacles to Internet and mobile support for chronic disease self-management. CONCLUSION: Patients with chronic diseases may have greater than expected difficulties in using Internet and mobile technologies for disease self-management, often due to cognitive impairment or unfamiliarity with technology. Approaches to dealing with such barriers include suitable integration of solutions involving patient-caregiver dyads, better design of online applications, careful attention to technology adoption and sustainability, and smart home technologies.

Can wireless text messaging improve adherence to preventive activities? Results of a randomised controlled trial.

OBJECTIVE: To determine the effectiveness of cell phone wireless text messaging for improving adherence to a healthy behaviour. DESIGN: A randomised, unblinded, controlled trial was conducted with 102 subjects, 18 years or older, each having a cell phone and willing to take 1 vitamin C pill per day for 1 month for preventive reasons. Intervention group participants received text messaging reminders and were asked to acknowledge receiving their messages after taking the vitamins, whereas control group subjects had no text messaging activity. MEASUREMENTS: Self-reported adherence and the number of participant text messages acknowledging vitamins taken. RESULTS: Both groups reported an increased adherence after the trial: by 246% for the intervention group and by 131% for the control group. There was a non-significant difference between the two groups at endpoint: an average difference of 0.8 between the number of pills missed in the last week of the trial (2.5 out of 7 in the intervention and 3.3 out of 7 in the control group) with a power of 0.54. The study revealed a significant correlation (coefficient=-0.352, sig.=0.01) between the average number of text messaging acknowledgements sent by the intervention group participants and the number of pills they reported missed during the last week of the trial. CONCLUSION: This was a small randomised controlled trial with inconclusive but encouraging results. It suggests a new approach in addressing insufficient adherence in outpatient conditions and shows that the use of information technology tools for compliance warrants further research.